dyspnea and delirum - palliative care network of wisconsin · dyspnea -- treatment oxygen think of...

Dyspnea and Delirium

David E. Weissman, MD Professor Emeritus, Medical College of Wisconsin Palliative Care Education, LLC 2015

Acknowledgement

This course was developed in 2004 with many revisions since then; Drs. Drew Rosielle and Kathryn Neuendorf were important contributors to past editions.

Objectives/Acknowledgement

▪ List three common causes of dyspnea and delirium in the dying patient.

▪ Review drug and non-drug treatments for dyspnea and delirium.

▪ Describe ethical principles when treating symptoms in the dying patient.

Disclaimer

While this program provides educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some of the information cites the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Case Question

▪ You are caring for a hospitalized man dying from lung cancer; currently on no opioids. The patient is sitting up, sweating, unable to talk or eat due to dyspnea. The goals of care have been established as symptom relief for this patient.

▪ Write an initial drug order for treatment of severe dyspnea in this patient?

Dyspnea -- Definition

▪ A subjective sensation of difficulty breathing ▪ An abnormally uncomfortable awareness of

breathing

Obstructive airway process Parenchymal / pleural disease

tracheal obstruction asthma COPD

aspiration diffuse primary or metastatic cancer lymphangitic metastases pneumonia pleural effusion pulmonary drug reaction radiation pneumonitis

Dyspnea -- Causes

Vascular disease Cardiac disease

pulmonary embolus superior vena cava obstruction pulmonary vascular tumor emboli

congestive heart failure pericardial effusion--malignant / other arrhythmia myocardial ischemia

Dyspnea -- Causes

Chest wall/ respiratory muscles Other

primary neurological disease (e.g. ALS) malnutrition

anxiety anemia constipation

Dyspnea -- Causes

Dyspnea -- Assessment

▪ How common is it?

▪ 50-70% in dying cancer patients ▪ 24% of cancer patients w/no cardiopulmonary disease ▪ 61% dying from cardiac disease ▪ 56-94% with COPD and restrictive lung disease

▪ Note: In symptomatic COPD, dyspnea ratings are better predictors of general health status than physiologic measurements

Dyspnea -- Assessment

▪ Patient rating: Numeric scale (1-10) ▪ Physical signs: sitting up, accessory muscles,

nasal flaring ▪ ADL’s: impairment of eating, talking, exercise

tolerance ▪ Lab/X-Ray: ▪ Assess the overall goals of care—this will help you

decide what if any level of testing is necessary to establish an etiology. If the goal is purely symptom relief until death, and death is felt to be imminent, then no or minimal diagnostics are necessary.

Dyspnea -- Treatment

▪ Non-Drug Treatments ▪ Positioning—sitting up ▪ Open window; Bedside fan ▪ Humidified air ▪ Noninvasive positive pressure mask ▪ Pulmonary rehab; Relaxation training ▪ Thoracentesis ▪ Radiation therapy ▪ Debulking Surgery ▪ Complimentary Medicine


▪ Drug Therapy—mainstay of symptomatic treatment is opioids ▪ Adjuvant to therapies aimed at reversing etiology or

when etiology cannot be reversed ▪ Opioids—best drug to alleviate symptom of dyspnea ▪ Usually small doses suffice, 5-15 mg of oral

morphine in opioid naïve patients. ▪ SQ or IV opioids for severe dyspnea or when patients are

unable to swallow; 1-5 mg morphine q 10 minutes.


▪ Benzodiazepines may help relieve associated anxiety. (e.g. lorazepam) ▪ Not first-line therapy but can be helpful adjuvant Note: when combined with opioids they will produce additive sedative/

CNS depressant effects which may or may not be desirable.

▪ Other drugs which can be added ▪ Cough suppressants ▪ Steroids ▪ Sedatives ▪ Inhaled local anesthetics


▪ Oxygen ▪ Think of Oxygen as any other drug

▪ not all dyspneic patients benefit ▪ Pulse oximetry will generally not be of benefit in

decision-making for treating terminal dyspnea ▪ Masks and positive pressure devices are poorly

tolerated; use nasal cannula ▪ Near the end of life, trial of 2-4 liters O2 ▪ For continued dyspnea use drug therapy (e.g.

opioids) rather than using higher flow rates or face mask.

Treating dyspnea and the “double effect”

The fear of using drug therapy to ease the distress of terminal dyspnea often leads to inadequate symptom control. Health professionals and the public often mistakenly equate use of drugs to ease terminal dyspnea with euthanasia or assisted suicide. ▪ Ethically, the use of these drugs are appropriate and essential, as

long as the intent is to relieve distress, rather than shorten life. ▪ There is no justification for withholding symptomatic treatment

to a dying patient out of fear of potential respiratory depression. ▪ Understanding the patient's wishes for symptom control,

and good communication with both family and other caregivers (e.g. nursing staff) regarding why drugs to relieve distressing dyspnea are administered, is essential to avoid misunderstanding.

Case Question

▪ You are caring for a hospitalized man dying from lung cancer; currently on no opioids. The patient is sitting up, sweating, unable to talk or eat due to dyspnea. The goals of care have been established as symptom relief for this patient.

▪ What is your initial order to treat this patient’s severe dyspnea?

Delirium

Delirium -- Definition

An acute, altered level of consciousness (arousal) associated with … ▪ Reduced attention and memory ▪ Perceptual disturbances—delusions and

hallucinations ▪ Incoherent speech ▪ Altered sleep-wake cycles

Delirium -- Spectrum

▪ Hyperactive Delirium ▪ Agitated, picking at clothes and bed covers,

rambling and loud incoherent speech

▪ Hypoactive Delirium ▪ Quiet, sleepy, little spontaneous movement, soft

incoherent speech ▪ More common than hyperactive delirium but is

often overlooked since patients are not “causing problems”

Differential Diagnosis

▪ Dementia ▪ Chronic and progressive loss of intellectual

(executive) function in setting of normal state of arousal/level of consciousness.

▪ Psychosis ▪ Relapsing and remitting hallucinations and

delusions with a normal state of arousal/level of consciousness.

Delirium -- Common Causes

▪ Drugs, Drugs, Drugs!!! ▪ Anti-cholinergics ▪ Anti-depressants, anti-secretory agents, anti-

emetics, etc. ▪ Benzodiazepines ▪ Opioids ▪ Steroids ▪ NSAIDs ▪ Alcohol/Illicit drugs ▪ Others

Delirium -- Common Causes

▪ Infections: UTI, pneumonia, sepsis ▪ CNS pathology: mets, bleed, infection ▪ Sleep deprivation ▪ Drug withdrawal: alcohol, benzo’s, opioids ▪ Metabolic: ▪ Hypercalcemia, hyper- or hypo-natremia,

hypercapneia ▪ Hypoglycemia, hypoxia ▪ Dehydration, uremia, hepatic encephalopathy

Delirium -- Common Causes (cont)

▪ Imminent death ▪ Approximately 80% of patients will exhibit a

hypoactive or hyperactive delirium in the days leading up to death.

Delirium -- Assessment

▪ Use a bedside mini-mental test. ▪ Determine if the patient is in danger of hurting

themselves or others. ▪ Review the medication history—this is typically the

most common and easily reversed problem. ▪ Formal assessment tools are available, such as

CAM


▪ Confusion Assessment Method (CAM) ▪ Validated assessment tool to help distinguish between

delirium and dementia ▪ Looks at different aspects of patient’s mental status to

evaluate for delirium ▪ CAM has been adapted for different settings, such as the

ICU ▪ Features evaluated to diagnose delirium include:

Inouye, SK et al. Clarifying confusion: The confusion assessment method. Annals of Internal Medicine 1990. 12:941-48.


▪ Assess the overall goals of care—this will help you decide what if any level of testing is necessary to establish an etiology.

▪ If the goal is purely symptom relief until death, and death is felt to be imminent, then no or minimal diagnostics are necessary.

Delirium -- Treatment

▪ Non-Drug Treatments ▪ A quiet, well lit room ▪ Have a family member present to relieve anxiety ▪ Avoid physical restraints ▪ Re-hydration—in selected cases may be of benefit.


▪ Drug Therapy—the primary drug class for terminal delirium are the antipsychotics (e.g. haloperidol). ▪ Although benzodiazepines are commonly used, they

may lead to paradoxical worsening of the delirium, especially in the elderly.


▪ Antipsychotics—a.k.a. neuroleptics ▪ For short-term use, there is no benefit of using

newer (atypical) vs. older drugs. ▪ Haloperidol or Chlorpromazine are readily available,

inexpensive and easy to administer. ▪ Dosing is similar to opioids for pain—give enough to

reduce the target symptom, there is no maximum dose. ▪ Starting dose of Haloperidol is 1-2 mg; can be given every

hour as needed to reduce symptoms until the patient has stabilized, then converted to a dose given every 6-12 hours.


▪ Haloperidol ▪ Many possible routes of administration ▪ Comparatively low propensity for sedation or

hypotension ▪ Few active metabolites ▪ Limited anticholinergic effects


▪ Benzodiazepines ▪ Use cautiously; watch for paradoxical worsening ▪ Additive CNS depressant effects with opioids ▪ Use when patient not controlled with antipsychotics

alone ▪ Use as first agent for delirium from EtOH withdrawal ▪ Lorazepam is preferred agent

▪ Rapid onset ▪ Shorter duration of action ▪ Low risk of accumulation ▪ No major active metabolites

Learning Points

List 3 new things you learned from this presentation.

1. 2. 3.

References--Dyspnea

Abernathy A, et al. Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea. BMJ 2003; 327:523-6

Bruera, E, Dalal, S and Palat, G. Chapter 25: Management of dyspnea.. In: Principles and Practice of Palliative Care and Supportive Oncology, 3rd edition. Berger A, Shuster JL and von Roenn JH (eds). Lippincott, Williams and Wilkins. 2007.

Bruera E, Schmitz B, et al. The frequency and correlates of dyspnea in patients with advanced cancer. J Pain Symptom Manage 2000;19:357-362.

Bruera E, Stoutz N, Velasco-Levla A, et al. Effects of oxygen on dyspnea in hypoxamic terminal cancer patients. Lancet 1993;342:13-14.

Janssens JP, Muralt B, Titelion V. Management of dyspnea in severe chronic obstructive pulmonary disease. J Pain Symptom Manage 2000;19:378-392.

Jennings AL, Davies AN, Higgins JP, et al.: A systematic review of the use of opioids in the management of dyspnoea. Thorax 2002, 57:939-44.

Navigante AH, Cerchietti LC, Castro MA, et al.: Midazolam as adjunct therapy to morphine in the alleviation of severe dyspnea perception in patients with advanced cancer. J Pain Symptom Manage 2006, 31:38-47.

Schwartzstein RM, Lahive K, Pope A, et al.: Cold facial stimulation reduces breathlessness induced in normal subjects.Am Rev Respir Dis 1987,136:58-61.

References--DeliriumAttard, A, Ranjith, G, Taylor, D. Delirium and its treatment. CNS Drugs. 2008;22(8):

631-44. Brietbart W, Marotta R, Platt M, et al. A double blind trial of Haloperidol,

Chlorpromazine and Lorazepam in the treatment of delirium. Am J Psych 1996;153:231-237.

Casarett DJ and Inouye SK. Diagnosis and management of delirium near the end of life. Ann Int Med 2001;135:32-40.

Centeno, C Sanz, A, Bruera, E. Delirium in advanced cancer patients. Pall Med 2004. 18(3):184-94.

Friedlander, MM. Delirium in palliative care. Oncology 204. 18(12):1541-50. Lawlor PG, Gagnon B, et al. Occurrence, causes and outcome of delirium in

patients with advanced cancer. Arch Int Med 2000;160:786-794. Lawlor PG. Et al. Occurrence, causes and outcome of delirium in patients with

advanced cancer. Arch Intern Med 2000; 160:786-794. Rousseau P. Palliative sedation in the management of refractory symptoms. J

Support Oncol 2004; 2:181-186. Shuster, JL. Chapter 39: Cognitive Disorders:Delirium and Dementia. In:Principles

and Practice of Palliative Care and Supportive Oncology, 3rd edition. Berger A, Shuster JL and von Roenn JH (eds). Lippincott, Williams and Wilkins. 2007.

dyspnea and delirum - palliative care network of wisconsin · dyspnea -- treatment oxygen think of...

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